Left-sided superior vena cava: diagnosis by magnetic ... - Springer Link

1 downloads 0 Views 144KB Size Report
showed the catheter passing along the left border of the heart. ... cardiac opacification on the right side was normally observed after injection of microbubbles ...
Intensive Care Med (1997) 23: 702–703  Springer-Verlag 1997

A. Boussuges P. Ambrosi M. Gainnier V. Quenee J.-M. Sainty

Received: 4 March 1997 Accepted: 21 March 1997

)

A. Boussuges ( ) ⋅ M. Gainnier ⋅ V. Quenee ⋅ J.-M. Sainty Service de Re´animation Me´dicale, Hoˆpital Salvator, 249 Boulevard de Sainte-Marguerite, BP 51, F-13274 Marseille Ce´dex 9, France FAX: + 33 (4 ) 9174 5435 P. Ambrosi Service de Cardiologie, Hoˆpital de la Timone, 254 Rue Saint Pierre, F-13385 Marseille Ce´dex 5, France

BR IEF R E P O RT

Left-sided superior vena cava: diagnosis by magnetic resonance imaging

Abstract We describe a case of leftsided superior vena cava. The diagnosis was suggested by chest radiograph after central venous catheter placement. This was subsequently confirmed by magnetic resonance imaging. Key words Vena cava ⋅ Systemic venous return ⋅ Congenital heart disease ⋅ Magnetic resonance imaging

Case report

Discussion

A 71-year-old man was admitted to the medical intensive care unit because of respiratory failure complicating pneumonia. The patient had a medical history of chronic obstructive pulmonary disease and left cardiac failure. At the time of admission he required mechanical ventilation. A central venous catheter was placed percutaneously for drug administration. The left internal jugular vein was punctured and the catheter inserted without difficulty. Blood return through the catheter was normal. A chest radiograph showed the catheter passing along the left border of the heart. Echocardiography did not disclose any anatomic anomalies, and cardiac opacification on the right side was normally observed after injection of microbubbles through the catheter. Then the catheter was withdrawn and a new catheter was placed through the right internal jugular vein in a usual position. Computed tomography confirmed the presence of a persistent left superior vena cava which probably drained into the left atrium. Cardiac magnetic resonance imaging (MRI) showed that the left superior vena cava was draining into the right atrium through a dilated coronary sinus (Figs. 1 and 2). The patient improved and was transferred out of the intensive care unit.

Persistence of a left-sided superior vena cava is a congenital anomaly resulting from the failure of the left cardinal vein to degenerate in utero. It has been estimated that this anomaly is present in 0.3 percent of the population [1]. The left superior vena cava drains into the coronary sinus (frequently dilated) and then into the right atrium. Drainage may occur more rarely into the left atrium. The diagnosis may be suspected when the chest radiograph shows the central venous catheter passing along the border of the left heart, and when good blood return through the catheter excludes malposition outside the central venous circulation. A bolus contrast injection confirms the anomaly. 2D echocardiography, with injection of microbubbles through the catheter, can be performed to investigate a dilated coronary sinus and associated cardiac abnormalities. Congenital abnormalities like atrial or ventricular septal defects and absence of the right superior vena cava may coexist [2, 3]. Rhythm disturbances are also frequently associated. In our opinion, the patient’s poor echogenicity explains

703

Fig. 1 MRI of the chest (oblique plane) showing left-sided vena cava Fig. 2 MRI of the chest (transverse plane) demonstrates a dilated coronary sinus (large arrow) opening into the right atrium (small arrow)

1

2

why 2D echocardiography was not contributive. Transesophageal echocardiography is more accurate but more invasive. The diagnosis can also be made with computed tomography or MRI. Electrocardiographically triggered MRI gives more accurate images of the heart than conventional computed tomography. Moreover, it can show mediastinal structures such as vena cava.

The intensivist should be aware of the occurrence of left-sided superior vena cava in order not to mistake catheters (central venous or pulmonary artery catheters) placed in it as being in the arterial circulation or malpositioned outside of the venous circulation. MRI is a useful and noninvasive method for demonstrating this anomaly.

References 1. Saunders JM (1946) Bilateral superior vena cava. Anat Rec 94: 657–659

2. Boyes R, Puri VK (1984) Absent right superior vena cava. Intensive Care Med 10: 45–46

3. Leibowitz AB, Halpern NA, Lee M, Iberti TJ (1992) Left-sided superior vena cava: a not so-unusual vascular anomaly discovered during central venous and pulmonary artery catheterization. Crit Care Med 20: 1119–1122